Patient Rights Advocate continues to misinterpret price transparency data with latest report

Once again, Patient Rights Advocate (PRA) has issued a report that misrepresents compliance with CMS price transparency regulations. (Read my March blog about a previous PRA report here.)

PRA’s most recent “Hospital Price Transparency Compliance Report,” published in July, examines websites of 2,000 U.S. hospitals. Its findings were that only 36% of those hospitals fully adhered to transparency rules. While PRA’s report does show an 11.5% uptick in hospital compliance compared to its previous assessment, this 36% compliance rate starkly contrasts with the 70% compliance rate published by Centers for Medicare & Medicaid Services (CMS) — the regulatory body that sets regulations and oversees compliance for the program — following its own review last year.

In my review of the report, I could see from the get-go that PRA doesn’t fully understand the federal rules. Two phrases PRA leans on to make points:

1. “Requires hospitals to post all prices online …” Every hospital in the U.S. does not provide or bill for “all items and services available and approved to be provided in the United States by all healthcare providers.” I point this out because it appears that in all of PRA’s “analysis” they insert that if an item or service does not appear on a hospital’s machine-readable file, they must be “hiding it” or skirting around “errors, overcharges, and fraud.”
2. “Requires to post all items, services, and drugs by all payers and all plans …” Every payer and plan that is available in a state, region or community of a hospital does not contract with every hospital and it is never appropriate for a hospital to state contracted rates for services if they do not have a contract secured with a payer and plan. PRA continues to make assumptions that hospitals and providers are in-network and contracted with payers and plans without verification of the payer/provider contract.

With that context, PRA asserts that “two-thirds of hospitals reviewed continue to hide their prices in various forms, causing financial harm to American patients, employers, unions, workers, and taxpayers every day.” Yet there are no specifics about what charges two-thirds of hospitals are concealing nor how they have supposedly uncovered them.

In its report summary, PRA says: “In February of 2023, CMS acknowledged in a blog post that 30% of hospitals (approximately 1,800) were still noncompliant. Yet, in April of 2023, only two more hospitals were fined. Both were still found to be noncompliant in this review. As of the time of this report, a total of four hospitals have been penalized, 0.2% of the hospitals that CMS recognized as noncompliant. Clearly, CMS is not strongly enforcing the rule.”

In reality, CMS initiated hospital compliance audits for the Hospital Price Transparency Rule in spring 2021. As of early 2023, CMS has reported conducting comprehensive reviews of more than 1,000 hospital websites and HFMA has been consistently hearing that CMS has been issuing compliance audit notifications and collaborating closely with these hospitals to resolve discrepancies in their interpretations of federal regulations, ensuring adherence and uniformity with the rule requirements among all types of healthcare providers in the U.S. To date, 14 of the audited hospitals have been unable to achieve compliance within CMS’s stipulated time frame and have incurred fines for non-compliance, representing only 1% of all audited hospitals.

In summary, price transparency regulation compliance is what the federal regulators say it is, not what PRA says. Hospitals and health systems persistently collaborate with regulators and industry stakeholders to adhere to both federal and state price transparency policies, encompassing the federal Hospital Price Transparency Rule and stipulations within the No Surprises Act.

According to CMS, its assessment in 2022 showed that 70% of hospitals are now in full compliance with the federal Hospital Price Transparency Rule. That was a remarkable 27% surge from the 2021 evaluation.

Conclusion

HFMA has long been a proponent of price transparency in healthcare, and personally, I have worked with providers and regulators for more than eight years on price transparency efforts at the state and national levels. This has meant assisting hospitals and the provider community in understanding, adhering to and steering purposeful patient and consumer benefits through price transparency initiatives. Much progress has been made, but make no mistake, there is much more to do.

But I take pride in the substantial achievements hospitals and providers have made during this period. Reports like PRA’s misguided price transparency compliance serve only to confuse a needed, but level-set national conversation around healthcare accessibility and costs.